Quiz HEENT

The nurse is performing an otoscopic examination on a client with a suspected diagnosis of mastoiditis. What assessment finding would confirm this possibility?

- A thick, red, and immobile tympanic membrane

Which characteristic of the gums should a nurse expect to assess in a client who is healthy?

- Pink, moist, firm

The nurse is preparing to examine the ears of an adult client with an otoscope. The nurse should plan to

- firmly pull the auricle out, up, and back.

The nurse assesses an adult client's head and neck. While examining the carotid arteries, the nurse assesses each artery individually to prevent:

- reduction of the blood supply to the brain.

During an eye assessment, the nurse is testing a client's visual acuity using a Snellen chart. In order to prepare the client for this component of assessment, what instruction should the nurse provide?

- "Cover one of your eyes and then read out the letters on the chart, starting from the top

A nurse is integrating health promotion education into the assessment of a client's mouth, nose, and throat. What interview question is most likely to identify a risk factor for oral cancer?

- "Do you use tobacco, whether smoking or chewing?"

A 2-month-old infant is being examined at the pediatrician's office. The mother said she noticed the baby was not making tears in the left eye. What does this finding suggest?

- A blocked lacrimal apparatus

A client has just undergone surgery for glaucoma and the nurse is providing discharge instructions, which of the following instructions should be included for post op eye surgery care?

- A shield or eye patch should be worn to protect the eye while healing

A client suffering from a headache complains of throbbing, severe, unilateral pain that feels worse when exposed to bright lights. The client also complains of nausea and vomiting. What is the nurse's best action?

- Administer migraine medication per MD order

Which risk factor for traumatic brain injury (TBI) should a nurse include in a discussion about prevention for a group of adolescents?

- Concussions in sports and motor vehicle accidents cause the largest number of TBIs in teens.

When assessing an adult client experiencing diarrhea, the nurse notes a round moon face, a buffalo hump at the nape of the neck, and a velvety discoloration around the neck. What is the possible cause of these signs?

- Cushing's syndrome

Why is it important to ask the client regarding discharge or drainage from the eyes?

- Discharge is associated with inflammation or infection

A nurse is caring for a hospitalized infant and is monitoring for increased intracranial pressure (ICP) and notes that the anterior fontanel bulges when the infant cries. Based on this assessment finding, which action would the nurse take?

- Document the findings

A 29-year-old physical therapist presents for evaluation of an eyelid problem. On observation, the right eyeball appears to be protruding forward. Based on this description, what is the most likely diagnosis?

- Exophthalmos

The nurse feels a small mass in the neck of a client. It is mobile in both the up-and-down and side-to-side directions. Which of the following is the nurse most likely feeling?

- Lymph node

In reviewing a client's health history, the nurse notes that the client has had a history of TMJ pain. The nurse recognizes that which of the following bones is involved in this dysfunction?

- Mandible

A client presents to the health care clinic and reports pain in the eyes when working on the computer for long periods of time. The client states that he almost ran into a parked car yesterday because he misjudged the distance from the bumper of his own car. He works for a computer software company and has noticed he is experiencing difficulty reading the manuals that accompany the software he installs for companies. What nursing diagnosis can the nurse confirm based on this data?

- Risk for Injury

The nurse is caring for a client who has been experiencing dysphagia secondary to a stroke. What risk nursing diagnosis should the nurse associate with this health problem?

- Risk for aspiration related to decreased swallowing ability

A client presents at the clinic complaining of a loss of balance. What test should the nurse expect the physician to carry out on a client with a loss of balance?

- Romberg test

The nurse is assessing an elderly woman who reports lethargy and weakness. During the examination, the nurse notices that the client's face is drooping slightly on the right side. Why does this finding require emergency intervention?

- The client could be experiencing a stroke

The nurse is caring for a patient who comes to the clinic reporting a lump by her ear. What are the symptoms of a cancerous lymph node?

- The node is fixed, nontender, and rubbery.

During a pharmacology class the students are told that some drugs need to be closely monitored. What should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides?

- Tinnitus and sensorineural hearing loss

The clinic nurse is assessing an older adult client who fell. The nurse asks if the client ever feels dizzy or has problems with balance. What is the nurse assessing for?

- Vertigo

When assessing for PERRLA, the nurse understands that the functional reflex allowing the eyes to focus on near objects is termed

- accommodation

The client is concerned because the sclera of the right eye has been pink in color for several days and tearing. What should the nurse suspect is occurring with this client?

- conjunctivitis